3 There are three techniques 1- Intra peritoneal only mesh ( IPOM )2- Trans abdominal pre peritoneal ( TAPP )3- Totally extra peritoneal ( TEP )In all techniques, three trocars are used.
4 IPOM TECHNIQUE- One from umbilicus- Other two trocars , lateral to rectus muscles- Mesh is placed to overlap the defect- Fixed with tacks, sutures or combination- It is not used in routine practice
5 TAPP TECHNIQUE- Trocar sites are same for IPOM- Periton is incised 2 cm above to hernia defect at the medial umbilical ligament and peritoneal flaps are created- Dissection of hernia sac- Placement of mesh- Closure of peritoneum- In TAPP and TEP, dissection area and mesh placement area the same. Difference is “ to approach to the pre peritoneal area”
6 TEP TECHNIQUETrocar position : There are two techniques1.- Umbilicus ( 10 mm )- Above the pubic arch ( 5 mm )- Midway between two trocars ( 5 mm)2.- Above the pubic arch ( 5 mm )- Medial to anterior superior iliac spine or the side of hernia (5 mm )
7 TEP –CONT.A- First trocar is applied in a plane between posterior surface of rectus muscle and posterior rectus sheath and peritoneum with balloon – preperitoneal retzius area are dissectedB- Second and third trocars are insertedC-1- First landmark is pubic bone and Cooper ligament2- Medially direct hernia reduction3- Laterally indirect hernia sac: superio-laterally from spermatic vessels. Medially vas deferens is dissected.
8 TEP CONT.- Cord parietalization to a point that crosses iliac vesselsPreperitoneal dissection should be so big that “ When preperitoneal area is closed, prosthesis should lie flat in the preperitoneal space and should not roll up.”D- Placement of mesh ( 12 x 15 cm polypropilen, polyester from umbilical port )E- Fixation with tacks, staples, biologic glue. Fixation should be applied superior to iliopectineal ligament.
9 IN GENERAL IPOM Advantages -Minimal dissection -Minimal postoperative painDisadvantages-Risk of bowel injury-Adhesive complications or herniations
10 TAPPAdvantages- Easier to learn, anatomy is more familiar for the surgen.- The work space is larger than TEP- Allows to see the hernia sac contentsDisadvantages- Potential intra abdominal injury risk- More time consuming than TEP- Potential adhesive complication at where peritoneum has been closed
11 TEP ADVANTAGES -reduced risk of potential intra abdominal injury -reduced risk of adhesive complications-operation time is less than TAPPDISADVANTAGES-learning curve is longer than TAPP-the working space is limited- inadvertently peritoneum can be torn.
12 CASE SELECTION TAPP preference - Recurrence after TEP Patients in who had radical prostatectomy operationPatients who has midline incision for major surgeryIn the absence of this two conditions TEP is preferred technique.
13 LAPAROSCOPY CONTRINDICATIONS Absolute- Infection- Coagulopathy- In whom general anesthesia has increased riskRelative- Previous surgery in Retzius space- Incarcerated sliding scrotal hernia